Clinical Informatics

Incontinence and trial of void coding

Incontinence and trial of void coding

The advice provided in the Australian Coding Standards (ACS) and coding rules does not clarify several issues:

Is significance relevant to whether the condition is to be coded or is ACS 0001 and ACS 0002 all that is needed to indicate relevance to the episode?

What is the definition of persistence which is required to be met before this condition can be coded (assuming it meets ACS 0001 or ACS 0002)?

Is it reasonable to assume that a Trial of Void is undertaken to confirm continence?

It is assumed that the answers to each of these three questions must be YES if the code is to be allocated.

Reference Material and notes on standard or coding rules

ACS 1808 Incontinence:

1: Significance is defined but the text does not indicate if significance is the requirement for inclusion in coding.

Incontinence is significant when:

Is not clinically considered to be physiologically normal

Is not clinically considered to be developmentally normal, or

Is persistent in a patient with significant disability or mental retardation “(significance in this context is not defined in the standard)

2: Assign only when:

2.1 the incontinence is persistent prior to admission,

2.2 Is present at discharge

2.3 Or persists for at least 7 (seven) days

Clarification of the standard

Incontinence must be significant to be coded? (TN200 Published 15 June 2009 – Status Current)

Answer provided – references ACS 0001 and ACS 0002 – therefore, which of the following is correct?:

A: Code if significant AND treated, investigated or monitored during the stay

Or

B: What is persistence?

Some clarification is provided in TN200 – which indicates that the specification is present on admission, and present at discharge are intended to specify that the incontinence is persistent. However persistent is not defined other than present at admission, present at discharge.

no indication of whether both are required

no indication of the length of the problem to indicate persistence. Does this require clinical documentation of the word persistent? Such documentation is not common. Is there a number of days which make the condition persistent?

Example from a specific patient record

Though individual records are invaluable to assist evaluation and clarification of coding rules, the rules are designed for generic application and therefore need to be written in a manner which clarifies the situation for all cases.

A disagreement between coders:

Coder A: Do not assign R32 as

no documentation to link the failed Trial of void with urinary incontinence

Coder B: Apply clinical knowledge would require assigning urinary incontinence as the TOV failed and IDC inserted. This meets 1801 as it is

significant – not physiologically or developmentally normal

Persists – was present before admission and after admission

Meets ACS 0001/0002 – was treated during the stay

An extract of the key components of the example record is provided (on the right).

What do you think? Please comment below…

Record:

Past History: obesity and mobility: She weighs 100kg and requires a hoist for transfers, she is currently able to transfer and walk with assistance.

She has failed two Trials of Void, and has a history of rectocele, cystocele and hysterectomy with plans to follow up with urologist and gynaecologist.

Postoperative course: Her pain did improve post-op, however progress with physiotherapy was very slow. She was seen by the Rehab team and long term rehabilitation was felt the appropriate plan of action.

Patient developed painful leg cramps which was felt likely due to her ongoing UTI. Vancomycin 1g BD was added to her regimen. She subsequently became pryrexic and this was treated symptomatically. She had attempted Trial of Void on the day before discharge which failed. She now has an indwelling catheter. She has resisted efforts to mobilise and has been noted to have very poor dietry intake.

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3 Comments

ACS 1808 was removed from the 11th edition ACS so the requirement now is really whether the condition in question (incontinence) meets ACS 0002 (which does now include the concept of significance). The extracted information I don’t think provides enough information to make an informed decision and does not even state the patient is incontinent. It would be stretch (in my opinion) to assign a code for incontinence on the basis of the patient having a failed TOV – that is, in the absence of actual documentation of the incontinence.

The statement: …………………..Though individual records are invaluable to assist evaluation and clarification of coding rules, the rules are designed for generic application and therefore need to be written in a manner which clarifies the situation for all cases……………….. OR ………………… is it that the ACS are invaluable in that they are designed for application to all (individual) episodes of care and assist with application of the correct codes to the clinical statement documented?

There is an issue not considered in the comment above: Coders are expected to apply their clinical knowledge – is incontinence required to be documented with TOV? or can it be assumed that this is the issue requiring the TOV to ensure that the patient is no longer incontinent?

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